Balloon catheter suturing systems, methods, and devices having pledgets

ABSTRACT

A direct visualization catheter includes an elongate shaft defining a lumen and having a distal end portion and a proximal end portion and a transparent balloon attached to the distal end portion of the shaft. The balloon includes a first layer comprising a thermoset polymer and a plurality of polymeric fibers at least partially embedded in the thermoset polymer and a second layer disposed on the first layer and comprising a hydrogel.

PRIORITY CLAIM OF PRIORITY

This application is a continuation of U.S. application Ser. No.15/003,924, filed Jan. 22, 2016; which claims the benefit of priorityunder 35 U.S.C. § 119 to U.S. Provisional Application Ser. No.62/106,936, filed on Jan. 23, 2015, and U.S. Provisional ApplicationSer. No. 62/107,068 filed Jan. 23, 2015, the entire contents of whichare hereby incorporated by reference.

TECHNICAL FIELD

This invention relates to balloon catheters suturing systems, methods,and devices. For example, balloon catheter suturing systems, methods,and devices provided herein can include pledgets.

BACKGROUND

Heart function can be significantly impaired when a heart valve is notperforming properly. Potential causes for heart valve malfunctioninclude dilation of an annulus around the valve, ventricular dilation,and a prolapsed or misshapen valve leaflet. When the heart valve isunable to close properly, blood within a heart chamber can leakbackwards, through the valve, which is commonly referred to asregurgitation. Valve regurgitation may be treated by replacing orrepairing a diseased valve. The most common method of correctingtricuspid valve regurgitation is to reduce the annulus by bringing theanterior and septal leaflets closer together using sutures. In somecases, precut sheet pieces of polytetra-fluorethylene (PTFE), also knownas pledgets, are used with the sutures to cushion the load of the sutureagainst host tissue.

Although open heart surgery is one method for treating the diseasedvalve, a less invasive methods of treatment would be more desirable formany patients. Minimally invasive procedures, however, are significantlylimited by the lack of adequate visualization through blood within apatient's beating heart. Accordingly, there is a need for alternativedevices and methods for treating heart valve disease that providesadequate visualization and suture delivery for users during a minimallyinvasive procedure.

SUMMARY

Balloon catheter suturing systems provided herein can be used to sutureone or more anatomical locations using less invasive techniques whileproviding visualization of the anatomical location.

In some aspects, balloon catheter suturing systems provided hereininclude an elongate shaft defining a lumen and having a distal endportion and a proximal end portion, a balloon attached to the distal endportion, and at least a first pledget secured to the balloon by aportion of the balloon catheter suturing system adjacent the balloon. Insome cases, the balloon catheter suturing system includes at least onefastener adapted to fasten the first pledget to an anatomic structurewhen the balloon catheter suturing system is positioned within apatient.

In some cases, the first pledget is part of the transparent wall. Insome cases, the first pledget is held by an internal pledget supportstructure within the transparent wall of the balloon. In some cases, thefirst pledget is held by a first pledget support structure outside thetransparent wall of the balloon distal to the balloon.

In some cases, balloon catheter suturing systems further comprise asecond pledget held by a second pledget support structure proximal tothe first pledget, wherein at least one fastener is adapted to fastenthe first and second pledgets together on opposite sides of the anatomicstructure. In some cases, the second pledget is positioned within thetransparent wall of the balloon. In some cases, the second pledget ispositioned outside of the transparent wall.

In some cases, the first pledget is defined by weakened sectionsdefining one or more tear lines around the first pledget in thetransparent wall. In some cases, the first pledget is adapted todelaminate from a portion of the transparent wall. In some cases, thetransparent wall comprises at least a first layer comprising a thermosetpolymer and a plurality of polymeric fibers at least partially embeddedin the thermoset polymer. In some cases, the transparent wall comprisesat least a second layer disposed on the first layer, wherein the secondlayer comprises a hydrogel.

In some cases, the balloon catheter suturing system can include atransparent wall including at least a first layer comprising a thermosetpolymer and a plurality of polymeric fibers at least partially embeddedin the thermoset polymer. In some cases, the transparent wall caninclude at least a second layer disposed on the first layer. In somecases, the second layer can include a hydrogel. In some cases, thepolymeric fibers can be electrospun fibers randomly oriented within thethermoset polymer. In some cases, the thermoset polymer comprise asilicone, such as polydimethylsiloxane (PDMS).

The balloon catheter suturing system can have any suitable balloonshape. In some cases, the balloon can be configured such that suturesare passed through the balloon. In some cases, the balloon can define aworking channel there through. In some cases, the balloon is a weepingballoon.

In some aspects, a method for repairing a heart valve in a patent caninclude advancing a balloon end of a balloon catheter into an atrium ofa heart, imaging a portion of a heart valve, passing a suture through atleast one detachable section to suture a portion of the heart valve tothe at least one detachable section, and separating the at least onedetachable section from the balloon catheter. The balloon catheter caninclude one or more elongate shafts in fluid communication with aballoon having a transparent wall. In some cases, the transparent wallcan define the at least one detachable section. In some cases, thetransparent wall can define multiple detachable sections. In some cases,a portion of a heart valve is imaged through the transparent wall usingan imaging element disposed within the balloon through the one or moreelongate shafts. In some cases, the at least one detachable section isseparated from the balloon catheter by deflating the balloon andremoving the balloon catheter from the heart. In some cases, thetransparent wall defines the one or more detachable sections withweakened tear lines that tear when the balloon is removed from theheart. In some cases, a plurality of sutures are attached to multipleparts of a heart valve through a plurality of detachable sections priorto separating the plurality of detachable sections. In some cases, theheart valve is a tricuspid valve. In some cases, a valve annulus issutured to the at least one detachable section.

The details of one or more embodiments of direct visualization devices,systems, and methods provided herein are set forth in the accompanyingdrawings and the description below. Other features, objects, andadvantages will be apparent from the description and drawings, and fromthe claims.

DESCRIPTION OF DRAWINGS

FIG. 1A is an illustration of an exemplary balloon catheter suturingsystem within a human anatomy. FIG. 1B is a perspective view of a distalend portion of an exemplary balloon catheter having detachable pledgets.

FIG. 2 is a perspective view of a distal end portion of anotherexemplary balloon catheter having a detachable pledget.

FIGS. 3A-3J depict another exemplary balloon catheter suture deliverysystem having a pair of pledgets disposed distal to the balloon. FIG. 3Adepicts a distal end of the system. FIGS. 3B and 3C depict a controllinghandle for the system. FIGS. 3D-3I depict the system being used tosuture the valve annulus of a tricuspid valve. FIG. 3I depicts thepledgets and suturing thread in isolation.

FIG. 4 depicts another exemplary suture system that can be used with aballoon catheter suture delivery system provided herein.

FIGS. 5A-5F show several examples of a balloon shapes that can be usedin balloon catheter suturing devices and systems provided herein.

FIGS. 6A-6D depict how an exemplary balloon catheter suturing systemprovided herein can be used to suture tissue and leave a pledget.

FIGS. 7A-7C and 8A-8C depict how another exemplary balloon cathetersuturing system provided herein can be used to suture tissue and leavepledgets.

FIGS. 9A-9C show cross-sectional views of various examples of a tubularbody that can be part of balloon catheter suturing devices and systemsprovided herein.

FIG. 10 illustrates a cross-sectional view of a balloon material, whichcan be used in balloon catheter suturing devices and systems providedherein.

FIG. 11A shows an e-spun fiber network. FIGS. 11B-11D arecross-sectional views of composite of silicone and polymeric fibers,which can be used in certain balloon catheter suturing devices andsystems provided herein.

FIGS. 12A-12B and 13 provide flowcharts of methods used formanufacturing balloon catheter suturing devices and systems providedherein.

FIG. 14 is a flowchart of a method securing a fastener to tissue duringa surgical procedure using balloon catheter suturing devices and systemprovided herein.

FIG. 15 shows an exemplary fastening portion, which can be used with orin balloon catheter suturing devices and systems provided herein.

FIGS. 16A-16C show cross-sectional views of an exemplary fasteningportion at a distal end portion.

FIGS. 17A-17G show various exemplary fasteners.

DETAILED DESCRIPTION

Balloon catheter suture devices, systems and methods provided hereininclude features that improve minimally invasive surgical techniquesused during a heart valve repair procedure such as, but not limited to,procedures that suture one or more heart valve leaflets. Exemplaryprocedures include those that bicuspidizes a tricuspid valve, edge toedge stitching techniques (or Alfieri stitches), mitral valve stitches,closures of paravalvular leaks, percutaneous paravalvular leak closure,and/or percutaneous closure of prevalvular leaks. The term “suture” isused herein to refer to any fastening of anatomical structures, whichcan be made with any suitable fastener including suturing thread, clips,staples, hooks, tacks, clamps, etc.

Balloon catheter suture devices, systems, and methods provided hereininclude pledgets retained at an external end of the balloon cathetersuturing device. The pledgets are adapted to be sutured to an anatomicallocation, separate from the balloon catheter, and remain with aresulting suture. As used herein, the term “pledget” will refer to apiece of material that is intended be sutured to an anatomical location.In some cases, the wall of the balloon can include portions arranged tobe sutured to an anatomical location through the transparent wall and toseparate from the remainder of the balloon catheter to become a pledget.In some cases, balloon catheter suturing devices, systems, and methodsprovided herein can include one or more pledgets held by the ballooncatheter suturing devices and systems provided herein and positionedinside and/or outside the balloon such that the pledget(s) can besecured to an anatomical location using one or more fasteners. In somecases, balloon catheter suturing devices, systems, and methods providedherein can include cooperating pledgets that are arranged to clamparound an anatomical structure have one or more fasteners passed therethrough.

Balloon catheter suture devices, systems, and methods provided hereincan allow for direct visualization of a target location, which canprovide anatomy and pathology identification as well as device placementvisual feedback to the physician user during a minimally invasivemethod. Balloon catheter suturing devices, systems, and methods providedherein can include an elongate, compliant balloon having a transparentwall. In some cases, the transparent wall can include portions arrangedto be sutured to an anatomical location through the transparent wall andto separate from the remainder of the balloon catheter. In some case,the balloon can include pores to allow for the balloon to “weep” toprovide a visually clear area surrounding the balloon. In some cases,the balloon wall (e.g., a transparent balloon wall) can have a structurethat limits the propagation of tears. In some cases, as discussed below,the balloon all can include polymeric fibers within a matrix of a secondmaterial.

FIG. 1A shows an exemplary balloon catheter suturing system 100 within ahuman anatomy. Balloon catheter visualization system 100 can be insertedinto a right atrium of a heart through a brachial vein or a jugularvein. As shown in FIG. 1A, balloon catheter suturing system 100 includesan elongate shaft or tubular body 112 having a proximal end portion 114with a proximal end 116 and a distal end portion 118 with a distal end120. Proximal end portion 114 can couple to a manifold 122. Distal endportion 118 can include an integrated camera (not shown), a fasteningtool 124 with a fastener and at least one balloon 108 (also described asballoon member). Integrated camera and fastening tool 124 can bedisposed within balloon 108. As shown in FIG. 1A, balloon 108 can form adistal tip of balloon catheter suturing system 100. The fastening tool124 can pass a fastener through the balloon to suture an anatomicallocation outside the balloon. The balloon can be filled with aninflation medium, such as saline solution, that can be safely deliveredto the patient, thus leakage from resulting holes in the balloon causedby the passing of the fastener through the balloon can be tolerated.

Balloon catheter suturing system 100 can include a pledget 126 locateddistal to fastening tool 124 such that a fastener delivered through theballoon is also delivered through pledget 126 to suture pledget 126 toan anatomical location. Pledget 126 can, in some cases, be a part of theballoon wall of balloon 108 adapted to tear away from the balloon wall.In some cases, pledget 126 is laminated to an outside surface of theballoon wall. In some cases, a balloon wall can include weakenedsections or weakened tear lines such that pledget 126 tears away fromballoon 108 to leave a pledget sized hole. In some cases, pledget 126can be held within balloon 108. In some cases, pledget 126 can be heldadjacent the exterior of balloon 108. These different options areexplained in further detail below.

In FIG. 1A, balloon catheter suturing system 100 includes at least onetubular body 112 defining a lumen (not shown). In some cases, ballooncatheter suturing system 100 can include multiple tubular bodies, inwhich each tubular body defines at least one lumen. Each tubular body112 can optionally include multiple lumens, for example, coaxial ornon-coaxial lumens. Balloon catheter suturing system 100 can have one ormore lumens that extend partially or fully thorough one or more tubularbodies 112. One or more lumens can be used as a conduit adapted toreceive components, e.g., integrated camera or fastener tools, and/orinflation media, e.g., saline. In some cases, one or more lumens can beadapted to jet inflation media, e.g., saline, into distal end portion118 of balloon catheter suturing system 100.

Manifold 122 generally connects an external fluid supply to one or morelumens of balloon catheter suturing system 100. Manifold 122 can includeone or more ports 128 to facilitate a fluid connection to anothermedical device or a fluid source. For example, port 128 can supplysaline solution into one or more lumens of tubular body 112. Manifold122 may be coupled to tubular body 112 directly or indirectly. In somecases, a flexible tubing, sometimes referred to as a strain relieftubing, is coupled between manifold 122 and the tubular body 112 at theproximal end 116 to provide a longitudinal tapered transition betweenmanifold 122 and tubular body 112. Flexible tubing can help to increasekink resistance of tubular body 112 at proximal end portion 114.

FIG. 1B depicts an distal end of exemplary balloon catheter system 100having a balloon 108 having tear lines 196, or weakened sections, in theballoon wall 164 that define pledgets 126. Pledgets 126 are adapted tobe sutured to anatomical locations and separated from balloon 108. Asshown in FIG. 1B, balloon catheter suturing system 100 that includes anelongate, tubular body 112 with a distal end portion 154. In FIG. 1B, adistal end 156 of distal end portion 154 can be either directly orindirectly coupled to a balloon 108. For example, tubular body 112 canbe coupled to balloon 108 indirectly by using an intermediate cathetershaft 157. As shown in FIG. 1B, intermediate catheter shaft 157 couplesto a proximal end 162 of balloon 108 and a catheter interface portion158 of tubular body 112.

In FIG. 1B, balloon 108 is disposed proximate to distal end 156 oftubular body 112. Balloon 108 can include the proximal end 162, a distalend 163 and a wall 164 that extends from an interior surface 165 to anexterior surface 166. As shown in FIG. 1B, balloon 108 forms a distaltip 170 of balloon catheter suturing system 100. As discussed herein,balloon 108 can be filled with an inflation media in an interior cavity168 defined between proximal and distal ends 162, 163. Also discussedherein, balloon 108 can include a weeping balloon structure, i.e., aballoon structure that defines one or more perforations 172 extendingthrough wall 164.

As shown in FIG. 1B, distal end of tubular body can include a pluralityof lumens 174. Each lumen of plurality of lumens 174 can longitudinallyextend through tubular body 112 entirely or partially there through.Each lumen can be formed from one of various cross-sectional shapes,e.g., circle, oval, slot, square, rectangular, triangular, trapezoid,rhomboid, or irregular shape. The shape of the lumen may facilitatereceiving other components of balloon catheter suturing system 100. Forexample, as discussed herein, one or more lumens 174 can be used toreceive a fastening tool (not shown), a camera 176, fiber optic lightcables (not shown), electrical cables (not shown), inflation media andcombinations thereof. In FIG. 1B, tubular body can define a centrallumen 178 for receiving a fastening tool (not shown) for delivering afastener (not shown), two lumens for receiving fiber optic light cables180, one lumen for delivering inflation media 182, and one lumen forreceiving camera 176.

Pledgets 126 can be sutured to an anatomical location and separated fromballoon 108 after suturing to become pledgets. In some cases, pledgets126 are laminated onto the wall of balloon 108 such that a resultinghole from the separation of the pledget is limited to the size offasteners passed through the wall of balloon 108. In some cases,pledgets 126 can be defined by weakened sections 196 of the balloon wallsurrounding each pledget 126 such that detachment of each pledget 126creates a pledget sized hole in balloon 108. In some cases, pledgets 126can each be secured to anatomical locations prior to separation. In somecases, an inflation medium flow can be reduced or stopped prior toseparation.

Balloon 108 of balloon catheter suturing system 100 can be a weepingballoon. Weeping balloon, in the context of the present disclosure,includes a balloon structure defining one or more perforations (alsodescribed as apertures or micropores, extending through a balloon wall).As such, weeping balloons can transfer inflation media through theballoon wall, from interior cavity to exterior surface of balloon 108.Transferring inflation media to exterior surface can provide a benefitof displacing blood from exterior surface of balloon 108 that wouldotherwise blur or obstruct visual imaging through balloon 108. In otherwords, inflation media transferred through the one or more perforationscan help keep the exterior surface visually clear. If you just put aballoon against an anatomical surface, blood can be trapped on theballoon surface and thus obscures the view, but inflation media (e.g.,saline) exiting the pores of a weeping balloon can wash away this bloodon the balloon surface adjacent to the wall. In some cases, a weepingballoon used in a balloon catheter suturing system or device providedherein can have at least 3 punctured holes. In some cases, weepingballoons used in balloon catheter suturing systems or devices providedherein can have between 3 and 10,000 punctured holes, between 3 and1,000 punctured holes, between 3 and 100 punctured holes, or between 3and 10 punctured holes. In some cases, the number and dimensions ofpunctured holes in a weeping balloon used in a balloon catheter suturingsystem or device provided herein allows for an inflation media flow rateof between 1 and 50 ml/minute. In some cases, systems and methodsprovided herein control an inflation media flow rate to be between 3ml/minute and 10 ml/minute. In some cases, a weeping balloon used inballoon catheter suturing systems and devices provided herein can havehundreds of holes that perfuse inflation media (e.g., saline) throughthe balloon and into the blood. In some cases, a weeping balloon used ina balloon catheter suturing system or device provided herein can have agreater pore density in portions of the balloon wall in the center ofthe field of view and a lower pore density around a periphery of thefield of view.

FIG. 2 is a perspective view of another example of a balloon cathetersuturing system 200. As shown, balloon catheter suturing system 200includes a tubular body 202 with distal end portion 204, a pledget 206,suturing thread 212, and an integrated camera 207 disposed within aballoon 208.

In FIG. 2, pledget 206 is held distal to balloon 208 by a pledgetsupport 205 that extends adjacent the balloon 208 from a lumen 209 at adistal end 219 of tubular body 202 within balloon 208 while anotherportion of fastening element 206 extends adjacent to balloon 208. Asshown in FIG. 2, a portion of pledget support 205 extends around anddistal to balloon 208 such that pledget 206 forms a distal tip 218 ofballoon catheter suturing system 200. In some cases, multiple pledgets206 can be included. In some cases, a portion of pledget 206 can extendthrough the balloon 208. In some cases, a portion of pledget 206 that isdisposed within interior cavity 214 can be subsequently extended througha wall of balloon 208 to an exterior environment during a medicalprocedure.

Balloon catheter suturing system 200 can include a fastening tool 210adapted to penetrate tissue, separate tissue, and/or deliver a fastener212 through the pledget and tissue, to secure a suture to tissue and/orto attach two pieces of tissues together. As shown, fastener 212 issuturing thread. In some cases, fastening tool 210 can be in the formof, for example, a needle, knife, scalpel, cutter and combinationsthereof. In some cases, staple, hook, tack, clamp, a clip, or othersuturing devices can be used instead of or with suturing thread 212.

As shown in FIG. 2, integrated camera 207 is disposed at the distal end219 of tubular body 202 to provide visual imaging of a patient's anatomyduring the medical procedure. Camera 207 may be fully or partiallydisposed within a lumen 220 defined by tubular body 202. The camera canbe coupled to electrical and/or optical cables (not shown) in lumen 220that extend longitudinally through tubular body 202 towards a proximalend portion of tubular body 202. In some cases, camera 207 iselectrically connected to the external electronics with wires throughlumen 220. In some cases, a bundle of fiber optic cables, each withtheir own lens (e.g., borescopes), can be connected to an eyepiece forviewing or a camera for electrical conversion and transfer to a screen.In some cases, camera 207 includes externally powered but internal LEDsto emit light so that the tissue can be seen. In some cases, systemsprovided herein have optical fibers and an external light source.

A rectangular-shaped balloon 208, as shown in FIG. 2, can be coupled todistal end 219 of tubular body 202. In FIG. 2, balloon 208 has aproximal end 222 and a distal end 224. Balloon 208 can define aninterior cavity 214 that extends between proximal and distal ends 222,224. Balloon 208 can be expanded by filling interior cavity 214 with aninflation media, such as saline solution.

Balloon 208 of balloon catheter suturing system 200 can be a weepingballoon. Weeping balloon, in the context of the present disclosure,includes a balloon structure defining one or more perforations (alsodescribed as apertures or micropores, extending through a balloon wall).As such, weeping balloons can transfer inflation media through a balloonwall, from interior cavity 214 to exterior surface of balloon 208.Transferring inflation media to exterior surface can provide a benefitof displacing blood from exterior surface of balloon 208 that wouldotherwise blur or obstruct visual imaging through balloon 208. In otherwords, inflation media transferred through the one or more perforationscan help keep the exterior surface visually clear. If you just put aballoon against an anatomical surface, blood can be trapped on theballoon surface and thus obscures the view, but inflation media (e.g.,saline) exiting the pores of a weeping balloon can wash away this bloodon the balloon surface adjacent to the wall. In some cases, a weepingballoon used in a balloon catheter suturing system or device providedherein can have at least 3 punctured holes. In some cases, weepingballoons used in balloon catheter suturing systems or devices providedherein can have between 3 and 10,000 punctured holes, between 3 and1,000 punctured holes, between 3 and 100 punctured holes, or between 3and 10 punctured holes. In some cases, the number and dimensions ofpunctured holes in a weeping balloon used in a balloon catheter suturingsystem or device provided herein allows for an inflation media flow rateof between 1 and 50 ml/minute. In some cases, systems and methodsprovided herein control an inflation media flow rate to be between 3ml/minute and 10 ml/minute. In some cases, a weeping balloon used inballoon catheter suturing systems and devices provided herein can havehundreds of holes that perfuse inflation media (e.g., saline) throughthe balloon and into the blood. In some cases, a weeping balloon used ina balloon catheter suturing system or device provided herein can have agreater pore density in portions of the balloon wall in the center ofthe field of view and a lower pore density around a periphery of thefield of view.

FIGS. 3A-3J depict another exemplary balloon catheter suture deliverysystem 300 having a pair of pledgets 322 and 324 disposed distal toballoon 308. FIG. 3A depicts a distal end of system 300. FIGS. 3B and 3Cdepict a controlling handle for the system. FIGS. 3D-3I depict system300 being used to suture the valve annulus 301 of a tricuspid valve.

As shown in FIG. 3A, balloon catheter suturing system 300 includes aninner pledget 322 and an outer pledget 324. Inner pledget 322, as shownin FIG. 3E, is held adjacent to a distal end of balloon 308 by an innerpledget support structure 332, which can extend through a channel formedin balloon 308, and outer pledget 324 is held distal to inner pledget322 by an outer pledget support structure 334. As shown in FIG. 3C,balloon catheter suturing system 300 can be manipulated by a controllinghandle 390 to position a distal end of system 300 as desired. As shownin FIGS. 3D-3I, the distal end can be manipulated to position tissue 301(e.g., a valve annuals of the tricuspid valve) between inner pledget 322and outer pledget 324 such that tissue 301 to be sutured there between.FIG. 3D depicts balloon catheter suturing system 300 after placement,but before suturing. FIG. 3E depicts system 300 after suturing threads312 a and 312 b have been pulled through tissue 301 and inner pledgetapertures 323 a and 323 b. FIGS. 3F-3H discussed below show how this isaccomplished, but do not show balloon 308 in order to more clearly showsteps. FIGS. 3I and 3J depict pledgets 322 and 324, suturing threads 312a and 312 b, and suturing attachments, needle shuttles 314 a and 314 b,in isolation.

FIGS. 3D and 3F depict inner pledget 322 placed on one side of tissue301 and outer pledget 324 positioned on an opposite of tissue 301 priorto suturing of tissue 301. As discussed above, balloon 308 is omittedfrom FIG. 3F for clarity. Although FIGS. 3A and 3D depict inner pledget322 as being external to balloon 308 with inner pledget supportstructure 332 and internal pledget support shaft 333 extending through aworking channel in balloon 308, some systems provided herein can have aballoon enclose inner pledget 322, internal pledget support structure332, internal pledget delivery shaft 333, and fastener tool 331. Outerpledget 324, outer pledget support structure 334, outer pledget deliveryshaft 335, suturing threads 312 a and 312 b, and needle shuttles 314 aand 314 b. Suturing threads 312 a and 312 b can be positioned such thatthey extended through outer pledget apertures 325 a and 325 b prior todelivery of balloon catheter suturing system 300 and retained in outerpledget apertures 325 a and 325 b by needle shuttles 314 a and 314 b,which can have a larger outer diameter than the inner diameter of outerpledget apertures 325 a and 325 b. Needle shuttles 314 a and 314 b caninclude stylet receiving apertures 315 a and 315 b adapted to lock withopposing distal anvils 311 a and 311 b of stylets 310 a and 310 b offastener tool 331, which are supported on stylets 310 a and 310 b. Innerpledget support structure 332, outer pledget support 334, and fastenertool 331 can be moved relative to each other by their respective shafts.Outer pledget support structure 334 is attached to outer pledgetdelivery shaft 335. As shown in FIG. 3F, inner pledget 322 and needleshuttles 314 a and 314 b can be spaced to allow for tissue 301 to slidethere between.

FIG. 3G depicts the advancement of the fastener tool 331 such thatdistal anvils 311 a and 311 b of stylets 310 a and 310 b pass throughinner pledget apertures 323 a and 323 b, such that opposing distalanvils 311 a and 311 b engage with stylet receiving apertures 315 a and315 b of needle shuttles 314 a and 314 b. Opposing distal anvils 311 aand 311 b can have a sharp point to facilitate piercing of tissue 301.As shown, fastener tool 331 can be positioned in a working channelformed along or through balloon 308. In some cases, fastener tool 331can be positioned within balloon 308 and stylets 310 a and 310 b canalso pierce balloon 308 prior to passing through inner pledget apertures323 a and 323 b. In some cases, balloon 308 is a weeping balloon that isresistant to tear propagation, thus balloon 308 can tolerate theformation of additional apertures formed in balloon 308 due to thepassage of stylets 310 a and 310 b through the balloon.

FIG. 3H depicts suturing threads 312 a and 312 b being pulled throughtissue 301, and through inner pledget apertures 323 a and 323 b when thefastener tool 331 (see FIG. 3G) retracts needle shuttles 314 a and 314 bproximally. In some cases, suturing threads 312 a and 312 b canadditionally be pulled into balloon 308.

FIG. 3I depicts inner pledget 322 secured against tissue 301 by suturingthreads 312 a and 312 b through holes. Outer pledget 324 is not shown inFIG. 3I, but is on an opposite side of tissue 301. Suturing threads 312a and 312 b can be subsequently tied off or otherwise secured tocomplete the suture.

In some cases, inner pledget 322 can be positioned within balloon 308.In cases where an inner pledget 322 is positioned within balloon 308, asshown in FIG. 3E, inner pledget support structure 332 and inner pledgetsupport shaft 333 can be positioned within balloon 308. In cases wherean inner pledget 322 is positioned within balloon 308, balloon 308 canbe torn or cut to be separated from inner pledget 322 after suturing. Insome cases, balloon 308 can be torn or cut to be separated from thepledgets 322 and 324. In some cases, a portion of a balloon wall betweenpledgets 322 and 324 can rip along weakened tear lines to remain a partof the suture and an additional pledget structure. In some cases,balloon 308 can rip to be allow inner pledget 322 to be separated fromballoon catheter suturing system 300.

Referring back to FIGS. 3B and 3F, balloon catheter suturing system caninclude a controlling handle 390 at a proximal end. Controlling handle390 can include a handle 395, a trigger 391 for controlling the bend 398of a tubular body 382 to control the placement of distal end of system300. Levers 392 and 393 and knob 374 can control the advancement and/orretraction of the fastener tool 331, inner pledget support shaft 333,and outer pledget support shaft 335. Levers 392 and 393 and knob 374 canalso control the tying of suture threads 312 a and 312 b. In some cases,inner pledget support shaft 333 is integral with tubular body 382 suchthat levers 392 and 393 control the movement of the fastener tool 331and the outer pledget support shaft 335 relative to the tubular body 382and the inner pledget support shaft 333. In some cases, knob 374 can beused to manipulate fastener tool 331 to tie suturing threads 312 a and312 b together.

Referring to FIGS. 3A and 3D again, a distal end of system 300 caninclude a plurality of channels 380 for delivery of inflation media,tools, fiber optics, cameras, etc. in tubular body 382. In some cases, acamera 376 can be integrated into shaft tubular body 382.

FIG. 4 depict another exemplary suture system that can be used with aballoon catheter suture delivery system provided herein. The suturesystem of FIG. 4 has stylet fasteners 412 a and 412 b for suturingtissue (e.g., a valve annulus of a tricuspid valve) in between an innerpledget 422 and an outer pledget 424. A balloon catheter suturing systemprovided herein can have a structure is similar to balloon cathetersuturing system 300 depicted in FIGS. 3A-3I, but uses the suturingsystem of FIG. 4 to suture tissue to inner pledget 422 and outer pledget424.

Inner pledget 422 can include inner pledget apertures 423 a and 423 b,which hold fasteners 412 a and 412 b. Fasteners 412 a and 412 b can bestylet fasteners having proximal anvils 413 a and 413 b and distalanvils 411 a and 411 b. Proximal anvils 413 a and 413 b can rest on anupper surface of inner pledget 422 to prevent stylet fasteners 412 a and412 b from passing entirely through apertures 423 a and 423 b. Distalanvils 411 a and 411 b are adapted to be received and locked into outerpledget apertures 425 a and 425 b in outer pledget 424. Stylet fasteners412 a and 412 b can be advanced to pierce tissue and insert the distalanvils into the outer pledget apertures 425 a and 425 b by advancing aninner pledget support structure, which can cover at least a portion ofproximal anvils 413 a and 413 b. Wires 414 a and 414 b can be releasablysecured to proximal anvils 413 a and 413 b to hold the stylet fasteners412 a and 412 b against an inner pledget support structure. FIG. 4depicts inner pledget 422 and stylet fasteners 412 a and 412 b that canbe advanced through tissue and distal anvils 411 a and 411 b that can bepushed into outer pledget apertures 425 a and 425 b. Accordingly, aninner pledget support structure and inner pledget support shaft act as asuturing tool.

FIG. 4 shows internal locking structures 428 within external apertures425 a and 425 b and how they lock distal anvils 411 a and 411 b ofstylet fasteners 412 a and 412 b. Outer pledget 424 can include aninternal plate 427. In some cases, pledget 424 can be formed byinjection molding a polymeric material around plate 427. Plate 427includes two plate apertures surrounded by locking structures 428, whichcan clasp and lock distal anvils 411 a and 411 b. Distal anvils 411 aand 411 b can be conical to push locking structures out as distal anvils411 a and 411 b are pressed against locking structures 428 until abottom edge of the conical tip passes a lower edge of locking structures428, which results in locking structures 428 snapping against a shaft ofstylet fasteners 412 a and 412 b. A bottom edge of the conical tip thusacts as a mechanical stop that locks the distal anvil from be retractedout of outer pledget apertures 425 a and 425 b. After the pledgets 422and 424 are secured together on opposite sides of tissue, wires 414 aand 414 b can be retracted from proximal anvils 413 a and 413 b.

Balloons used in the balloon catheter suturing systems of FIGS. 1A-4Fcan use any suitable balloon shape. As discussed above, in some cases,pledgets are held external to the balloons. In some cases, balloons caninclude one or more working channels for one or more tools (e.g.,pledget support shafts, fastening tool, etc.) to access an anatomicalstructure (e.g., a tricuspid valve). In some cases, a working channelcan have a balloon extend along three sides of the channel. In somecases, a working channel can be surrounded by a donut-shaped balloon. Insome cases, balloons used in balloon catheter suturing systems 100, 200,or 300 can include tools within the balloon. In some cases, tools withinthe balloon can pass through the balloon wall to access anatomicalstructures. In some cases, a pledgets can be a part of the balloon wall,can be located within a balloon, or held adjacent an outer surface ofthe balloon. FIGS. 5A-5F depict exemplary balloon shapes 500, 520, 540,560, 580, and 590, which can be used in balloon catheter suturingdevices and systems provided herein. Although not specifically shown inFIGS. 5A-5D, each of these balloon shapes 500, 520, 540, and 560 caninclude side working channels and/or through working channels.

Balloons can be constructed from various forms, e.g., a film, sheet ortube of transparent materials. Also, balloons 500, 520, 540, 560, 580,and 590 may be formed into a variety of different shapes. FIG. 5A showsan example of a balloon 500 having a generally oval shape. FIG. 5Bprovides an example of a balloon 520 having a proximal spherical portion522 and a distal spherical portion 524 with a necked portion 526 therebetween. FIG. 5C provides an example of a balloon 540 having a proximalspherical portion 542 that transitions into a distal flared portion 544.FIG. 5D shows an example of a balloon 560 having a proximal conicalportion 562 coupled to a distal bulbous portion 564. FIG. 5E shows anexample of a donut-shaped balloon 580 having a channel or thru lumen582. Thru lumen 582 can be sized and shaped to allow blood or othermedical devices to pass through. FIG. 5F shows an example of ahalf-flask shaped balloon 590 having a side working channel 592. In somecases, balloons used in balloon catheter suturing devices and systemsprovided herein have a diameter of between 0.5 cm to 4 cm. In somecases, balloons used in balloon catheter suturing devices and systemsprovided herein have a diameter of between 1.0 cm to 2 cm. In somecases, balloons used in balloon catheter suturing devices and systemsprovided herein can provide a field of view of between 0.5 cm to about 3cm. In some cases, balloons used in balloon catheter suturing devicesand systems provided herein can provide a field of view of between 1.0cm to about 2.0 cm. In some cases, balloons used in balloon cathetersuturing devices and systems provided herein can provide a field of viewof about 1.5 cm. In some cases, the ratio of longitudinal balloon lengthversus diameter is approximately 1:1 with the camera's angle of viewbeing about 30 degrees.

Balloon 500, 520, 540, 560, 580, and 590 can be a compliant balloon thatfills with an inflation media, which inflates balloon from a smallerdeflated size to a larger inflated size thus allowing a larger device tobe transferred through the catheter. Balloon 500, 520, 540, 560, 580,and 590 can be adapted to be filled with inflation media suppliedthrough one or more lumens of a tubular body, e.g., tubular body 112 ofFIG. 1, from a fluid source that connects to a manifold at a proximalend of tubular body 112. In some cases, balloon 500, 520, 540, 560, 580,and 590 can be filled with inflation media, e.g., saline solution, tofacilitate visualization through camera, e.g., camera 207 of FIG. 2, ata distal end portion of a direct visualization catheter. Balloon 500,520, 540, 560, 580, and 590 can facilitate visualization in severalways. In some cases, balloon 500, 520, 540, 560, 580, and 590 can beused to visualize anatomical features within the anatomy when pressedagainst a targeted anatomical feature and inflation media flows out ofpores to clear an exterior surface of balloon of blood. In some cases,balloon 500, 520, 540, 560, 580, and 590 can be composed of materialsthat are optically transparent when exposed to a particular inflationmedia and/or bodily fluids.

Balloon 500, 520, 540, 560, 580, and 590 as well as other medical devicecomponents, can be constructed of various materials that are opticallytransparent when exposed to inflation media, e.g., saline solution,and/or bodily fluids, e.g., blood. In some cases, balloon 500, 520, 540,560, 580, and 590 can be constructed of various transparent materialsthat maintain transparency within the body over a desired duration. Forexample, suitable balloon materials can have anti-fouling properties,e.g., materials resistant to protein-binding and platelet adsorption,which maintain transparency over longer durations than materials thatare do not have anti-fouling properties. The term “fouling” generallyrefers to a material that undesirably accumulates foulants, such asbiomacromolecules, microorganisms, hydrocarbons, particles and colloids,from the surrounding environment. Anti-fouling properties, also referredto as a “stealth effect,” reduces intermolecular forces of interactionsbetween foulants and the balloon material. In some cases, such as inimplantable applications, balloon materials can have anti-thrombogenicproperties to prevent the formation of clots in the body. In some cases,balloon 500, 520, 540, 560, 580, and 590 can include a hydrophilicmaterial. Hydrophilic materials can allow the saline to preferentiallybe wet over allowing the air to contact the surface. In some cases, anyair bubble which may occur in the balloon can be flushed out of thefield of view or broken up.

Balloon 500, 520, 540, 560, 580, and 590 may be constructed of variousmaterials having physical, mechanical or functional properties that canimprove device performance. Furthermore, these various materials can beincorporated at specific locations of the balloon where specificfunctional properties are desired. For example, balloon 500, 520, 540,560, 580, and 590 can be constructed of various materials that areself-healing. Self-healing refers to a structural ability of a material,e.g., fiber-reinforced polymers, to repair mechanical damage. In anotherexample, balloon 500, 520, 540, 560, 580, and 590 may be constructed ofvarious materials having suitable mechanical properties, such as tensilestrength, ductility and elastic modulus. In some cases, at least aportion of a balloon material can have a Shore A hardness of 90 or lessto provide the balloon with suitable flexibility. In another example,balloon 500, 520, 540, 560, 580, and 590 can be constructed of variousmaterials having suitable lubricity. Lubricity can help facilitateproper balloon placement within the anatomy and minimize blood vesseland tissue damage otherwise caused by balloon 208 or alternative medicaldevices.

FIGS. 6A-6D depict an exemplary balloon camera view of a balloon 610including a pledget section 646 in a balloon wall 611 defined by tearoff notches in the balloon wall. FIG. 6A depicts the balloon 610 priorto having a fastener 624 (e.g., a staple or a suture) passed through thepledget section 646 and into tissue surrounding the pledget detachablesection 646. FIG. 6B depicts the balloon 610 having pledget detachablesection 646 sutured by fastener 624 (e.g., a staple or a suture) totissue on an exterior surface of the pledget detachable section 646.FIG. 6C shows the balloon 610 having a hole 658 from where the pledgetdetachable section 646 was removed, and FIG. 6D depicts the suturedpledget 656.

FIGS. 7A-7C illustrate a camera view showing how detachable sections 746can be sutured to an anatomical location and separated from balloon 710.FIGS. 8A-8C depict a view of this procedure from a position distal tothe balloon. As shown in FIGS. 7A and 8A, a balloon 710 can includepledget detachable sections 746 and a through working channel 722,through which a suturing thread rides with a fastening tool (not shown).The fastening tool working channel 722 can be a central hole or pore inballoon 710. As shown in FIG. 7A, each pledget detachable section 746includes tear notches 747. As shown in FIGS. 7B, 7C, 8B and 8C, a suturethread 712 can be passed into working channel 722 by a fastening tool(not shown), piercing tissue outside of balloon 710 and piercing pledgetdetachable section 746 of the wall of balloon. In some cases, as shownin FIGS. 7C and 8C, after an initial suture is made, balloon 710 can bemoved or retracted to separate the sutured pledget 756 from the balloon710. In some cases, multiple pledget detachable sections 746 are suturedto different anatomical locations prior to separating the pledgetdetachable sections 746 from balloon 710 to product sutured pledgets756. In some cases, the pledget detachable sections 746 are laminated toan outer surface of the balloon wall such that removal of pledget 756does not produce a pledget sized hole in balloon 710. In some cases,pledget detachable sections 746 are defined by a weakened score line toproduce a tear line around pledget detachable sections 746.

FIGS. 9A-9C show cross-sectional views of various examples of tubularbodies 900, 920, 940, which can be used in balloon catheter suturingdevices and systems provided herein. In FIG. 9A, tubular body 900includes a plurality of lumens that includes a central lumen 902 and aplurality of non-central, surrounding lumens 904. Plurality ofnon-central, surrounding lumens 904 of FIG. 9A includes four circularsurrounding lumens 906 and one rectangular surrounding lumen 908.Central lumen and surrounding lumens can be formed of various sizes andshapes. For example, as shown in FIG. 9A, central lumen 902 can belarger than some or all non-central, surrounding lumens 904. In somecases, as shown, some of the non-central, surrounding lumens 904 can belarger than other surrounding lumens. In some cases, tubular body 900may have only non-central, surrounding lumens 904, i.e., no centrallumen. In some cases, tubular body may have one lumen or multiple lumen,for example, up to 15 lumens.

In FIG. 9B, tubular body 920 includes a plurality of lumens thatincludes a central lumen 922 and plurality of non-central, surroundinglumens 924. Plurality of non-central, surrounding lumens 924 of FIG. 9Bincludes three circular surrounding lumens 926, one rectangularsurrounding lumen 928, and six slot-shaped lumens 930.

In FIG. 9C, tubular body 940 includes a plurality of lumens thatincludes a central lumen 942 and plurality of non-central, surroundinglumens 944. Plurality of surrounding lumens 944 of FIG. 9C includesthree circular surrounding lumens 946, one rectangular surrounding lumen948, and six curvilinear, slot-shaped lumens 950.

Balloon catheter suturing devices and systems provided herein mayinclude a balloon constructed of one or more polymeric, transparentmaterials. In some cases, at least a portion of the balloon can beconstructed of a polymeric fibrous matrix or a polymer film. In variouscases, the balloon is constructed of a modified thermoset polymer (alsodescribed as a composite of polymeric fibers and polymers).

FIG. 10 shows a cross-sectional view of a balloon material that includesa modified thermoset polymer 1000. As shown, polymer 1000 includes aninner layer 1002 (which may also be referred to as a first layer) and anouter layer 1004 (which may also be referred to as a second layer).Inner and outer layers 1002, 1004 of FIG. 10 each includes one or morepolymeric materials. In particular, inner layer 1002 of FIG. 10 includesa thermoset polymer 1008 and a plurality of polymeric fibers 1010(represented by crosshatch lines in the figure) embedded withinthermoset polymer 1008. As shown in FIG. 10, thermoset polymer 1008 isembedded with individual fibers that make up the plurality of polymericfibers 1010. In some cases, polymer 1008 can fully or partially fillspace between some of the individual fibers. Described differently,thermoset polymer 1008 can interpenetrate the space between individualfibers that make up the plurality of polymeric fibers 1010. In somecases, thermoset polymer 1008 can covalently bond to the individualfibers. In some cases, polymer 1008 can mechanically engages with theindividual fibers by interlocking with at least a portion of theplurality of polymeric fibers 1010. Exemplary materials of variousthermoset polymers 1008 include, but are not limited to, polyurethanes,silicones, phenolic polymers, amino polymers, epoxy polymers andcombinations thereof. FIGS. 11B-11D depict cross-sectional views of anexemplary composite that includes polymeric fibers embedded within asilicone thermoset polymer.

Suitable silicones may include, but are not limited to,polydimethylsiloxane (PDMS), polydiphenylsiloxane,polymethylphenylsiloxane, fluorosilicones such as polymethyl(3,3,3-trifluoropropyl)siloxane and combinations thereof. Theplurality of polymeric fibers 1010 of FIG. 10 can be randomly oriented.In such cases, the plurality of polymeric fibers 1010 may form anonwoven fibrous matrix. In some cases, the plurality of polymericfibers 1010 can be oriented in a regular pattern. The plurality ofpolymeric fibers 1010 oriented in a regular pattern may form a wovenfibrous matrix. The nonwoven fibrous matrix can provide the benefit ofproviding multiaxial strength to a material while the woven fibrousmatrix can provide uniaxial strength directed to a particular axis.

Polymeric fibers can be constructed of biocompatible materials includingvarious thermoplastic materials. In particular, fibers may be formed ofthermoplastic materials suitable for electrospinning, force spinning ormelt-blowing processes. Electrospinning is a process that useselectrical charge to create fibers from a liquid while force spinning isa process that uses centrifugal force to create fibers. Melt-blowing isa process in which a molten thermoplastic resin is extruded through adie and then stretched and cooled with high-velocity air to form long,fine fibers. In some cases, fibers can be constructed of variouspolymers that exhibit hydrophilic or hydrophobic characteristics. Insome cases, fibers can be raw e-spun fibers, such as those shown in FIG.11A.

Suitable polymers for fibers can be formed from fluoropolymersincluding, but not limited to, for example, polytetrafluoroethylene(PTFE), polyvinylidene fluoride (PVDF) (e.g. Kynar™ and Solef™),poly(vinylidene fluoride-co-hexafluoropropene) (PVDF-HFP), cyclicfluoropolyethers such as Cytop™, perfluoroalkoxy alkane resins (PFA),poly(pentafluorostyrene), poly(2,2,3,3,4,4,4-heptafluorobutylmethacrylate), fluoroethylene-alkyl vinyl ether (FEVE; Lumiflon™),poly[4,5 difluoro 2,2bis(trifluoromethyl)-1,3-dioxole-co-tetrafluoroethylene, andcombinations thereof. Other suitable polymers for forming fibers areurethane-based polymers that include, but are not limited to, forexample, polyurethanes, polyurethane elastomers (e.g. Pellethane),polyether-based polyurethanes (e.g. Tecothane), polycarbonate-basedpolyurethanes (e.g. Bionate and/or Chronoflex) and combinations thereof.Other examples of suitable polymer materials for fibers can include, butare not limited to, polycarbonate, polyether, polyester, polyamide,nylon 6, nylon 12, nylon 66, nylon 10, nylon 11, polyetherimide andcombinations thereof. In some embodiments, fibers are formed from blockpolymers such as, for example, a poly(styrene-b-isobutylene-b-styrene)(SIBS) tri-block polymer and/or a polyisobutylene polyurethane(PIB-PUR).

Polymeric fibers can have diameters in the range of about 40 nanometers(nm) to 10,000 nm, for example. The fiber diameter size can include arange of about 100 nm to 3,000 nm. In some examples, suitable fiberdiameter sizes can include ranges of about 40 nm to 2,000 nm, about 100nm to 1,500 nm or about 100 nm to 1,000 nm, for example. In stillfurther examples, fibers 412 can have average fiber diameters rangingbetween about 900 nm to 10,000 nanometers or between about 800 nm to10,000. In some cases, fibers 912 are nanofibers having diameters lessthan 1,000 nm. For example, nanofiber diameters can range from about 100nm to 800 nm, or be any value there between. In some examples, nanofiberdiameters can range from 100 nm to 400 nm.

Outer layer 1004 of FIG. 10 can include one or more hydrogels (alsodescribed as crosslinkable, hydrophilizing agents). Hydrogels are anetwork of hydrophilic polymer chains that are bonded together byassociation bonds, such as hydrogen bonds and intermolecular hydrophobicassociations. Hydrogels have structures that are capable of retaininglarge amounts of water. In various cases, outer layer 1004 includeshydrogels that are optically transparent in vivo, i.e., when placed intoa body. In some cases, outer layer 1004 includes hydrogels havinganti-fouling properties, for example, are resistant to protein bindingand platelet adsorption. In some cases, hydrogels are anti-thrombogenic.Material having anti-fouling properties provide the advantage of beingoptically transparent for longer durations in vivo. Anti-thromobogenicmaterials provide implantable components and devices with a benefit oflong-term biocompatibility in vivo.

Various suitable hydrogels include, but are not limited to, olefin basedpolymers such as a polyethylene glycol (PEG) or a PEG derivative, forexample, PEG-dimethacrylate, UV-curable PEG, PEG diacrylate,polyethylene glycol-neopentyl glycol diacrylate methyl acrylate(PEG-NPDGA), PEG-Bioslide™, PEG-Z-Glide™, chitosan-PEG, thiol-PEG,maleimide-PEG, amino-PEG, azide-PEG, and carboxyl-PEG. Examples of othersuitable hydrogels include, but are not limited to, polyvinylpyrrolidone(PVP), polyvinyl acetate (PVA), glycosaminoglycans (e.g. heparin), poly[N-(2-hydroxypropyl) methacrylamide] (PHPMA), poly(vinyl pyrrolidone),polyethylene/oligoethylene, polyHEMA, polytetraglyme, hyaluronic acid,chitosan and any derivatives thereof.

In some cases, at least a portion of the hydrogel is embedded with aplurality of polymeric fibers 1010. In some cases, the hydrogel cancovalently bond to individual fibers that make up the plurality ofpolymeric fibers 1010. In some cases, the hydrogel can bond toindividual fibers by chemical association bonding, such as hydrogenbonding and/or intermolecular hydrophobic associations. In some cases,the hydrogel can mechanically engage with at least a portion of theplurality of polymeric fibers 1010 by interpenetrating space betweenindividual fibers protruding from a surface of an adjacent layer. Forexample, as shown in FIG. 10, the plurality of polymer fibers 1010 ispartially embedded in a portion 1012 of outer layer 1004 locatedadjacent the inner layer 1002. In some cases, the hydrogel can also beincorporated with a polymer solution from which spun fibers are formed.As a result, hydrophilic polymer chains can be intertwined or entangledwith another polymer.

In some cases, selection portions of the different layers shown in FIGS.10 and/or 11B-11D can be treated to create weakened portions of theballoon to create tear lines for separating a pledget section of aballoon wall. In some cases, the polymeric fiber layers can have be cutalong desired tear lines prior to combining the fibers with thethermoset polymer.

FIG. 12A is a flowchart of an example method 1200 of manufacturingballoons provided herein, such as balloon 108, 208, 310, 410, 618, 500,520, 540, 560, 580, and 590, 1810, 1910, or 2010. An initial set ofoperations 1211, 1212, 1213 forms an inner layer of balloon and anysubsequent operations 1214 forms an outer layer of balloon. At operation1211, a plurality of polymeric nanofibers (or, alternatively, aplurality of polymeric fibers) are formed into an interior cavity of aballoon mold using an electrospinning process. In some cases, theelectrospinning process can leave sections uncovered to produce weakenedsections. Alternatively, a plurality of polymeric nanofibers can bepreformed into a thin, nonwoven fibrous matrix film or sheet. In somecases, a thin, nonwoven fibrous matrix film or sheet can have scorelines cut into to produce weakened tear lines. Once preformed, nonwovenfibrous matrix film or sheet can be rolled and placed into the interiorcavity of the balloon mold. In some cases, nanofibers may be constructedusing processes other than the electrospinning process, for example, aforce spinning process.

At operation 1212, a curable thermoset material, e.g.polydimethylsiloxane (PDMS), in liquid form is injected into the mold.Thermoset material at least partially penetrates the plurality ofnanofibers.

At operation 1213, thermoset material is cured to form a pre-formedballoon.

At operation 1214, pre-formed balloon is removed from balloon mold andan exterior surface of the pre-formed balloon is treated with acrosslinkable, hydrophilizing agent, such as PEG-dimethacrylate,described herein. Following the treatment, the hydrophilized balloon maycontinue on to other manufacturing operations to build a directvisualization catheter or an alternative medical device.

FIG. 12B is a flowchart of another example method 1200 of manufacturingballoons provided herein, such as balloon 108, 208, 308, 408, 500, 520,540, 560, 580, and 590, or an alternative tubular component. An initialset of operations 1210, 1220, 1230 forms an inner layer of balloon andoperation 1260 forms an outer layer of balloon. At operation 1210,thermoset material is injected into a balloon mold using a curablethermoset material and only partially cured.

At operation 1220, a plurality of polymeric nanofibers are formed ontopartially cured thermoset material using an electrospinning process oralternative process, such as force spinning. Because thermoset materialis not fully cured, at least a portion of plurality of polymericnanofibers penetrates into thermoset material such that nanofibers areexposed at an exterior surface of balloon. In some cases, theelectrospinning process and/or the force spinning process can arrangethe delivery of fibers to create weakened tear lines in a resultingballoon.

At operation 1230, thermoset material is cured to form an inner layer ofa pre-formed balloon. Thermoset material may be cured as describedherein.

At operation 1240, pre-formed balloon is optionally removed from balloonmold and, at operation 1250, per-formed balloon is inverted such that atleast a portion of plurality of polymeric nanofibers are exposed alongan exterior surface of balloon. In some cases, operation step 1250 maynot be necessary if during operation, at least a portion of theplurality of polymeric nanofibers penetrates into thermoset materialsuch that fibers would be exposed at exterior surface of a non-invertedballoon.

At operation 1260, exterior surface of the pre-formed balloon is treatedwith a crosslinkable, hydrophilizing agent, e.g., PEG-dimethacrylate,described herein. Following the treatment, a hydrophilized balloon maycontinue on to other manufacturing operations, if applicable.

FIG. 13 is a flowchart of another example method 1300 of manufacturingballoons provided herein, such as balloon 108, 208, 308, 408, 500, 520,540, 560, 580, 590, or an alternative tubular component. An initial setof operations 1310, 1320, 1330 forms an inner layer of balloon andsubsequent operation 1340 forms an outer layer of balloon. At operation1310, a curable thermoset material, e.g. polydimethylsiloxane (PDMS), isextruded or overmolded onto a shaped mandrel. The mandrel can be formedin various balloon shapes or tubular shapes.

At operation 1320, a plurality of polymeric nanofibers are formed on ashaped mandrel using an electrospinning process or a force spinningprocess. The plurality of polymeric nanofibers are formed onto thermosetmaterial such that at portion of the nanofibers penetrates intothermoset material and another portion of the nanofibers remains exposedat an exterior surface of the balloon. In some cases, theelectrospinning process and/or the force spinning process can arrangethe delivery of fibers to create weakened tear lines in a resultingballoon.

At operation 1330, thermoset material is fully cured to form an innerlayer of a pre-formed balloon. Thermoset material may be cured asdescribed herein.

At operation 1340, the pre-formed balloon is treated with acrosslinkable, hydrophilizing agent, such as PEG-dimethacrylate,described herein. A hydrophilized balloon may be removed from themandrel at any time after thermoset material has been cured.Hydrophilized balloon may be subject to subsequent manufacturingoperations to build a direct visualization catheter or an alternativemedical device.

FIG. 14 is a flowchart of a method 1400 for securing a pledget andfastener to a target area, e.g., a left atrium of a heart, during asurgical procedure using a balloon catheter suturing system inaccordance with some of the embodiments provided herein. At operation1410, a target area within a patient can be located and initiallyinspected by advancing at least a portion of the balloon cathetersuturing system to the target area. In some cases, balloon cathetersuturing system or portions thereof, e.g., a visualization portion, isadvanced to the target area to provide visual or ultrasound images ofthe target area. In some cases, the balloon catheter suturing system orportions thereof, e.g., a visualization portion, can be advanced to thetarget area over a guidewire or within a guide catheter. Once at thetarget area, the balloon catheter suturing system or portions thereofcan provide direct visual images or ultrasound images for theinspection. In some cases, inspection can also include injectingcontrast media into the targeted area and viewing the area usingfluoroscopic equipment.

At operation 1420, the balloon catheter suturing system, is advanced tothe target area and a portion thereof expanded at the target area tostabilize the balloon catheter suturing system. In some cases, a balloonor stent is expanded to stabilize the balloon catheter suturing system.

At operation 1430, a desired surgical location at the target area can beverified by using direct visual or ultrasound imaging provided by theballoon catheter suturing system. In some cases, a primary cameralocated in balloon or stent portion of catheter can be used to verifythe surgical location. In some cases, the balloon catheter suturingsystem includes a secondary visualization portion that can be used inconjunction with the primary camera to visually verify the surgicallocation. In such cases, primary camera may provide anterior visualimages and the secondary visualization portion may provide posteriorvisual images. At operation 1440, the balloon catheter suturing systemcan be manipulated such that a pledget or pledget section of a balloonis positioned near or at the desired surgical location. In some cases, adistal end portion of direct visualization catheter can be deflected ata specific angle to position one or more pledgets in a desired location.In some cases, a select portion of direct visual catheter is advanced tothe desired location.

At operation 1450, the tissue is pierced using a fastening tool. In somecases, a portion of the balloon catheter suturing system, e.g., aneedle, can be used to pierce tissue at the surgical location. In somecases, the balloon catheter suturing system can advance a fastener, suchas a staple or clasp, such that the fastener pierces the tissue at thesurgical location and a pledget section of a balloon. In some cases, theadvancement of the fastener can interlock the fastener with a pledget.

At operation 1460, fastener is attached to tissue and the pledget orpledget section of a balloon. In some cases, attaching the fastener totissue can include securing a suture through tissue at the surgicallocation and through a hole in a pledget. In some cases, attachingfastener to tissue can include attaching a pledget, staple or clasp totissue at the surgical location through a pledget section of a balloonwall.

At operation 1470, the fastener and pledget are released from theballoon catheter suturing system. In some cases, a pledget section of aballoon wall is torn away from the balloon by retracting the balloon. Insome cases, the pledget is released from the catheter using an actuatorat a proximal end of the balloon catheter suturing system. In somecases, fastener is released from the catheter using an actuator at aproximal end of the balloon catheter suturing system. In some cases,pledget and/or fastener is released from the catheter by advancing aportion of the catheter, e.g., a pusher rod, to push the fastener awayfrom a distal end of the catheter. In some cases, pledgets and/orfastener, such as a suture thread, may not be released from the catheteruntil multiple surgical areas have been secured with the fasteners andpledgets.

FIG. 15 shows an exemplary fastening tool 1500, which can be used inballoon catheter suturing systems provided herein. Fastening tool 1500includes a tubular main body 1502 with a distal end portion 1504, aproximal end portion 1506, and a lumen (not shown) therethrough that issized to receive a fastener 1508. As shown, tubular main body 1502 canbe generally straight. In some cases, a portion of tubular main body1502, e.g., a distal end portion 1504, can be pre-formed to bend at asuitable angle or have a curvature that allows fastening tool 1500 tobetter access target tissue areas during a surgical procedure. In somecases, tubular main body 1502 can be deflectable such that the distalend portion 1504 can deflect to different angles during the procedure.

Distal end portion 1504 of fastening tool 1500 includes a distal end1514 and defines a distal opening 1516 adapted to receive andtemporarily retain fastener 1508. As shown in FIG. 15, in some cases,opening 1516 is adapted to retain a ring-shaped fastener 1508. Fasteningtool 1500 can be coupleable to various types of fasteners 1508, forexample, suture, a suture with a pledget, clips, and/or staples.Fastening tool 1500 can be used to deliver and affix fastener 1508 totissue, e.g., annulus of a heart valve.

Proximal end portion 1506 can include a proximal end 1518 and defines aproximal opening 1520 adapted to receive fastener 1508. In FIG. 15,proximal end portion 1506 has a sleeve 1522 adapted to receive at leastone rod, e.g., a push rod 1524 and/or an insertion rod 1526. Insertionrod 1526 can be used to load fastener 1508 into sleeve 1522. Push rod1524 can be used to advance fastener 1508 through sleeve 1522 intotubular main body 1502. Push rod 1524 can be sized and shaped to bereceived through a lumen (not shown) of tubular main body 1502 and beextended from distal opening 1516. In some cases, a single rod can beused as both push rod 1524 and insertion rod 1526.

FIGS. 16A-16C show cross-sectional views of an exemplary fastening tool1600, which can be used in balloon catheter suturing systems providedherein, at a distal end portion 1602. Fastening tool 1600 can include atubular body 1604 defining a lumen 1606 adapted to receive a fastener1608, e.g., an annulus clasp, and a distal end 1610 defining a distalopening 1612. As shown in FIGS. 16A-16C, fastener 1608 can be advancedthrough distal end portion 1602 of fastening tool 1600 and released fromfastening tool 1600 at distal opening 1612. Lumen 1606 can be sized andshaped to receive fastener 1608. Lumen can also be sized and shaped toreceive at least a portion of a push rod 1614. Push rod 1614 can be usedto about a proximal end 1616 of fastener 1608 and be translated distallyto push fastener 1608 to distal end 1610 of fastening tool 1600. Distalopening 1612 can be adapted to allow fastener 1608 to pass through. Asshown, in some cases, distal end 1610 can include a sensor 1618 thatindicates when fastener 1608 has reached distal opening 1612. Sensor1618 can provide location information of fastener 1608 to indicate whenfastener 1608 is ready to be released from fastening tool 1600. Sensor1618 may also be used to prevent accidental release of fastener 808.

In FIG. 16A, push rod 1614 and fastener 1608 are located at distal endportion 1602 of fastening tool 1600 proximate to distal opening 1612. InFIG. 16B, push rod 1614 and fastener 1608 are distally translated suchthat distal end 1620 of fastener 1608 begins to emerge from distalopening 1612. In some cases, as shown, distal end 1620 of fastener 1608can begin to form into a preformed shape, e.g., begin to curl into aring-like clasp. In FIG. 16C, push rod 1614 is further distallytranslated such that fastener 1608 extends from distal opening 1612 in apartially deployed state. As shown in FIG. 16C, fastener 1608 can curlinto a semi-circular shape in partially deployed state. Fastener 1608can be fully deployed to form a full ring by further distallytranslating push rod 1614 such that fastener extends completely fromdistal opening 1612. Fastener 1608 can be transitioned from thepartially deployed state to the fully deployed after the device has beenproperly positioned at a target surgical location. Fastener 1608 can befastened to tissue when transitioned from the partially deployed stateto the fully deployed state. In some cases, sensor 1618 can be used toidentify that fastener 1608 is ready to be fully deployed prior to beingreleased from fastening tool 1600.

FIGS. 17A-17G show various exemplary fasteners 1700, 1710, 1720, 1730,1740. As discussed herein, fasteners can be formed of various shapes andsizes. Suitable types of fasteners include, but are not limited to, forexample, a suture, staple, hook, tack, clamp or a clip. Fasteners can bemade of various polymeric and metallic materials. Suitable materials forfasteners include, but are not limited to, for example, polyethylene,polypropylene, polycarbonate, PEEK, stainless steel, nitinol andcombinations thereof. As shown in FIGS. 17A and 17B, fastener 1700, 1710can be a single body 1702, 1712 with sharp tips 1704, 1714 adapted topenetrate tissue on each end. As shown in FIG. 17A, body 1702 offastener 1700 can define at least one thru-hole 1706. In some cases,thru-hole can be sized to receive a suture (not shown). A single bodyfastener 1700, 1710 can be reshaped such that sharp tips 1704, 1714 canbe easily joined together and attached to tissue. As shown in FIGS. 17Cand 17D, fastener 1720, 1730 can include two or more portions coupledtogether by a hinge connector 1722, 1732 that allows tissue penetratingtips 1724, 1734 to join together. Possible fastener designs are notlimited by the examples provided herein, as one skilled in the art couldcontemplate other various structures that could be used to penetratetissue and/or connect suture to tissue.

FIGS. 17E-17G show another exemplary fastener 1740 that can be formed ofa single body 1742 that can be shaped into multiple configurations.Fastener 1740 can be shaped in a first configuration (see FIG. 17E)prior to implantation and a second configuration (see FIGS. 17F and 17G)during and after implantation. In some cases, fastener 1740 can be madeof a shape memory material or a malleable material. Fastener 1740 can bemade of various shape memory metals or polymers and be pre-formed into adesired final shape. In some cases, fastener 1740 can be fixed intosecond configuration by a connector, such as a clip 1741, as shown inFIG. 17G.

As shown in FIG. 17E, fastener can be shaped as a flat segment 1744 infirst configuration when being delivered by a direct visualizationcatheter (or a direct visualization system) to a surgical site. Fastenercan form into the desired final shape, e.g., a ring-like clasp 1746 asshown in FIGS. 17F and 17G, in second configuration when implanted intoa patient.

A number of embodiments of the direct visualization devices, systems,and methods have been described. Nevertheless, it will be understoodthat various modifications may be made without departing from the spiritand scope of the subject matter described herein. Accordingly, otherembodiments are within the scope of the following claims.

What is claimed is:
 1. A balloon catheter suturing system comprising: anelongate shaft defining a lumen and having a distal end portion and aproximal end portion; a balloon attached to the distal end portion, theballoon being a weeping balloon having a transparent wall defining atleast one detachable section; and a suturing tool positionable withinthe elongate shaft to pass one or more fasteners therethrough, whereinthe suturing tool is configured to pass the one or more fastenersthrough the at least one detachable section.
 2. The balloon cathetersuturing system of claim 1, wherein the weeping balloon includes atleast three punctured holes through a wall thereof.
 3. The ballooncatheter suturing system of claim 2, wherein the weeping balloon allowsfor an inflation media flow rate of between 1 and 50 ml per minute. 4.The balloon catheter suturing system of claim 1, wherein the weepingballoon has a plurality of pores, with a greater pore density in acenter of a field of view through the elongate shaft and a lower poredensity around a periphery of the field of view.
 5. The balloon cathetersuturing system of claim 1, wherein the transparent wall comprises atleast a first layer comprising a thermoset polymer and a plurality ofpolymeric fibers at least partially embedded in the thermoset polymer.6. The balloon catheter suturing system of claim 5, wherein thetransparent wall comprises at least a second layer disposed on the firstlayer.
 7. The balloon catheter suturing system of claim 6, wherein thesecond layer comprises a hydrogel.
 8. The balloon catheter suturingsystem of claim 7, wherein the hydrogel comprises polyethylene glycol(PEG).
 9. The balloon catheter suturing system of claim 7, wherein thehydrogel envelopes about a portion of the plurality of polymeric fibersprotruding from the first layer and mechanically engages with a portionof plurality of polymeric fibers.
 10. The balloon catheter suturingsystem of claim 9, wherein the thermoset polymer comprisespolydimethylsiloxane (PDMS).
 11. The balloon catheter suturing system ofclaim 5, wherein the plurality of polymeric fibers are electrospunfibers.
 12. The balloon catheter suturing system of claim 5, wherein theplurality of polymeric fibers are randomly oriented within the thermosetpolymer.
 13. The balloon catheter suturing system of claim 5, whereinthe plurality of polymeric fibers comprises a polyurethane.
 14. Theballoon catheter suturing system of claim 5, wherein the thermosetpolymer comprises a silicone.
 15. The balloon catheter suturing systemof claim 1, wherein the transparent wall comprises weakened sectionsdefining one or more tear lines around the at least one detachablesection.
 16. The balloon catheter suturing system of claim 15, whereinthe transparent wall is resistant to tearing along lines other than theone or more tear lines around the at least one detachable section. 17.The balloon catheter suturing system of claim 1, wherein the transparentwall defines at least two detachable sections.
 18. A balloon cathetersuturing system comprising: an elongate shaft defining a lumen andhaving a distal end portion and a proximal end portion; a weepingballoon attached to the distal end portion, the weeping balloon having atransparent wall defining a plurality of pores extending therethroughand at least two detachable sections; and a suturing tool positionablewithin the elongate shaft to pass one or more fasteners through the atleast two detachable sections.
 19. The balloon catheter suturing systemof claim 18, wherein the transparent wall comprises at least a firstlayer comprising a thermoset polymer and a plurality of polymeric fibersat least partially embedded in the thermoset polymer.